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Full text of "United States Navy Medical News Letter Vol. 33 No. 8, 17 April 1959"

NavMed 369 




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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 33 Friday, 17 April 1959 No. 8 



TABLE OF CONTENTS 

Chronic Lead Poisoning 2 

Prognosis in Essential Hypertension , 4 

Treatment of Acute Renal Failure , 6 

Pulmonary Cystic Disease , 9 

Segmental Resection for Pulmonary Tuberculosis 11 

Study of Patients with Acute Large Bowel Obstruction 13 

Prophylactic Castration in Carcinoma of the Breast 16 

From the Note Book 18 

A Letter from the Surgeon General 21 

Board Certifications - Inactive Reserve Officers 21 

Opportunities Open in Nuclear Subnnarine Medicine Program 22 

Report of Caisson Disease or Diving Accident - NavMed 816 . 23 

Recent Re search Reports . 23 

Poliomyelitis - Letter Report (BuMed Inst 6220. 2) 25 

Dependents' Medical Care in Certain Jurisdictions (BuMed Notice)6320) . 25 

Hospital Corpsmen - Training and Utilization (BuMed Notice 1306) 25 

DENTAL SECTION 

Officers Selected for Long Courses of Instruction , 26 

New Vice President for Dental Research Association 27 

Reenlistments of Dental Technicians 27 

Revised Dental Standards for Women , 27 

RESERVE SECTION 

Training in the Naval Reserve 28 

AVIATION MEDICINE SECTION 

Full Pressure Smt Program .... 30 Health Hazards 38 

Liquid Oxygen 34 New Carrier 39 

Intraocular Pressure 37 Aviation Physiology Training. . . 39 

Miniature Flight Surgeons' Wings 40 



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Medical News Letter, Vol. 33, No. 8 



Chronic Lead Poisoning 

This article reviews 7 years' experience with the problem of chronic 
lead poisoning in infants and children in a large children's hospital. 

Lead poisoning is still a significant cause of mortality and morbidity 
in children. Without question, the most important cause of chronic lead 
intoxication in children is ingestion of lead -containing substances. Scattered 
small epidemics of acute intoxication due to inhalation of lead fumes from 
burning storage battery casings have been reported. Of the substances in- 
gested by children, the most widely reported are paint from walls and wood- 
work and plaster. Other sources are painted furniture and painted or lead 
toys. In earlier times, lead nipple shields and body powders containing 
lead were common sources. 

In most reported series, the age range of children with lead intoxica- 
tion is from one to 4 years, the time of life when incidence is highest for 
all acute toxic ingestions. However, since only small amounts of lead can 
be absorbed and retained at one time, the abnormal appetite or pica, to 
cause toxicity, must persist for several months. 

Symptoms, when present, almost always relate to the gastrointestinal 
or central nervous systems. Among the frequent and significant symptoms 
are anorexia, vomiting, constipation, abdominal pain, irritability, convul- 
sions, drowsiness, incoordination, and pallor. Less commonly reported 
symptoms include personality change, tremors, and diarrhea. A prodrome 
of minor gastrointestinal symptoms, such as constipation or abdominal pain, 
and central nervous symptoms, such as lethargy, may precede by as much 
as 2 weeks the onset of more serious symptoms of vomiting, coma, or con- 
vulsions. Although the symptoms of lead intoxication are obviously non- 
specific, their association with a history of pica may prove significant. 

Often, there are no abnormal physical findings, especially when there 
is no severe central nervous system disease. Among the most commonly 
observed signs are pallor, motor weakness, coma, convulsions, papille- 
dema, hyper-reflexia, and ataxia. Respiratory center depression and dia- 
phragmatic paralysis have also been reported. "Lead lines" on the gums 
which are common in adult plumbism are quite unusual in children. 

Almost all children with chronic plumbism have a significant anemia 
with associated basophilic stippling of the red cells and elevated reticulo- 
cyte counts. The stippling and anemia are possibly due to interference by 
lead with the incorporation of protoporphyrin into hemoglobin. 

Lines of increased density in the metaphyses of the long bones as seen 
by roentgenography are almost always present in children with plumbism. 
These lines are not diagnostic nor are they areas of increased lead deposition; 
actually, they are areas of differential calcification. Other bones may also 
show "lead lines. " The laboratory tests which confirm a diagnosis of chronic 
lead poisoning are the demonstration of abnormally high levels of lead in the 
blood and urine. 



Medical News Letter, Vol. 33, No, 8 



Although many factors from history, physical examination, and labora- 
tory study suggest lead intoxication, there is no single pathognomonic find- 
ing. Children may have no symptoms, although their blood or urine lead 
concentrations are definitely above normal. Such children might receive 
a diagnosis of potential, subclinical, or asymptomatic lead poisoning. The 
most significant data for establishing a diagnosis are a definite history of 
pica for lead -containing substances, suggestive signs and symptoms, 
anemia with stippling, "leadlines" on x-ray, increased lead and copro- 
porphyrin levels in the urine, and increased lead concentration in the blood. 
The final diagnosis rests on the clinician's judgment after evaluation of the 
data at hand. 

During the period 1950 through 1956, 43 patients were treated at 
Children's Hospital, Washington, D. C. , because of chronic lead poisoning. 
No cases of acute lead poisoning, such as is caused by inhalation of lead 
fumes were observed. 

This group of patients with chronic lead poisoning was treated with 
EDTA. BAL was not used. EDTA was given either intravenously or sub- 
cutaneously in the standard dosage of 30 mg. per kilogrann per day; in the 
first 18 cases, 0. 5 gm. was given 3 times daily regardless of weight; EDTA 
was given for 5 days, discontinued for 3 days, and then repeated for 5 days. 
In the present series, no evidence of local or systemic toxicity from EDTA 
was noted. In general, treatment was dictated by the clinical status of the 
individual because the result of the chemical studies for lead were usually 
not reported for one to 2 weeks and then frequently did not correlate well 
with the severity of the symptoms. The most critical problem in therapy 
is the management of the child with lead encephalopathy who is in status 
epilepticus or coma. Craniotomy and reduction of spinal fluid pressure by 
repeated lumbar puncture were not consistently used in the present series; 
the authors found too few data on which to base conclusions as to their effi- 
cacy. Intensive supportive nursing care, parenteral anticonvulsants, res- 
tricted parenteral fluids, and parenteral EDTA were the mainstays of ther- 
apy. Oral EDTA has not been used in recent years because preliminary work 
showed very little promise. 

The observed mortality of 7% in 43 patients is significantly high even 
though it is an improvement over that noted in many previous reports. More 
important, the 45% incidence of neurologic and psychiatric residual mor- 
bidity deserves serious consideration and further study. Chronic lead poi- 
soning has become an increasingly significant problem as awareness of the 
diagnosis, treatment, and residuals has increased. Because lead enceph- 
alitis is an important killer and crippler of children, early diagnosis and 
therapy (with EDTA), as well as adequate and continued follow-up, are 
essential. The simple expedient of routine inquiry into the presence of 
pica will bring to light many cases of plumbism before they become symp- 
tomatic. Counseling, also, directed at cessation of pica seems to be an 
effective tool in prevention of continued lead poisoning. Perhaps even more 



Medical News Letter, Vol. 33, No. 8 



important are the roles of the private physicians, public health author- 
ities, and lawmakers in preventing the occurrence of this dangerous dis- 
ease through education of the public, inspection and proper repair of sub- 
standard housing, and more stringent laws regarding lead -containing paints. 
(Cohen, G. J. , Ahrens, W. E. , Chronic Lead Poisoning - A Review of Seven 
Years' Experience at the Children's Hospital, District of Columbia: J. 
Pediat. , 54:271-283, March 1959) 

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Prognosis in Essential Hypertension 

When referring to life insurance and judging the significance of dif- 
ferent forms of therapy in connection with the long-term prognosis in essen- 
tial hypertension, it is important to know as much as possible about the 
prospective length of life postulated for eux untreated group of hypertonics. 

The material for this study consists of patients who were treated in 
several medical departments in Oslo before 1944, for different ailments, 
and in whom essential hypertension was discovered casually. The patients 
had had no special treatment for their hypertension. 

The group consists of patients who were under 46 years of age at the 
time of the registration. The mean age on registration was 38 years for 
women and 37 years for men. Most of the patients were over the age of 35 
when first examined. Those included in the material were found to have a 
maximum systolic blood pressure of l60 mm. Kg or inore, or a maximum 
diastolic blood pressure of 95 mm. Hg or more. 

There were 290 patients of whom 179 (62%) were women, and 111 (38%) 
were men. This group was recalled for examination several times. In 1950- 
1951, it was found that 52 women (29%) and 46 men (41%) had died; this mor- 
tality was primarily the result of hypertensive disease in a majority of cases. 
The average period between registration and follow-up examination for the 
survivors was about 10 years. 

Arterial hypertension is not a disease, but a symptom. In this inves- 
tigation, all proved cases of secondary hypertension, as well as all cases 
with complications which could be thought to influence the prognosis, were 
excluded. 

In the present material, the mean age is lower than in most other 
surveys. The range in age difference is also sniall because only individuals 
under 46 years were recorded, thereby preventing to a certain degree the 
chance of including patients who have been hypertensive for a longer time 
as well as partly eliminating the factor of natural increase in blood pres- 
sure with increasing age. 

In isolated observations, as in larger materials, it has been shown 
that patients can live for a long time with considerably increased blood pressure. 



Medical News Letter, Vol. 33, No. 8 



However, investigations have shown that high blood pressure commonly has 
a serious prognosis. 

In this series it was found that a high systolic blood pressure over 
ZOO mm, Hg was niore frequent in those individuals who later died than in 
those who survived. It is well known that the mortality in essential hyper- 
tension is greater in men than in women. In this material, 58% of the men 
and 42% of the women died. The difference is so great that one must reckon 
that the female organism is better able to withstand high blood pressure than 
is the male. 

Levy and associates divided their nnaterial as follows; (1) patients with 
sustained hypertension with relatively fixed increased blood pressure not 
falling below a value of 160 mm. Hg systolic and not below 100 mm. Hg dia- 
stolic; and (2) patients with transient hypertension in whom bed rest produced 
a fall in blood pressure below the mentioned values. Because this classifica- 
tion depends to some extent on estimation the authors undertook to character- 
ize blood-pressure types more exactly and thus have chosen as a basic char- 
acter the diastolic pressure. They have classified the blood-pressure types 
into "labile" and "stable" diastolic pressure. 

"Labile" diastolic hypertension was diastolic blood pressure which fell 
to values below 95 mm. Hg after bed rest and sedatives. Such "labile" 
diastolic blood pressure was found at registration in 97 individuals of whonn 
28% of the men and 13% of the women died during the observation period. 
In the group having "stable" diastolic hypertension in which such a fall was 
not found, there was a mortality of 54% in women and 75% in men during the 
period of observation. 

Investigations of mortality with methods used for life-insurance inves- 
tigations give a good idea of the prognosis. Comparison with the population 
mortality table gives a fair inipression of the death rate when the age range 
is considered. The death rate for individuals belonging to the group with 
"labile" blood pressure was only 8. 3 for women and 20. 3 for men per 1000 
observation years. This is almost the same as for the total population in 
the corresponding age group. On the contrary, individuals with "stable" 
diastolic blood pressure showed a death rate of 47. 3 per 1000 observation 
years for women and 99. 3 per 1000 observation years for men; that is, 
about five times the normal death rate both for men and for women. 

The causes of death in essential hypertension are cerebral, cardiac, 
or renal. Often, several of the systems are affected at the same time. The 
renal death rate is higher in the earlier investigations, but in more recent 
and larger investigations, the proportion of renal deaths is about 10%. In 
this material, the renal death at follow-up investigation was found to be 9% 
in 1950 - 1951 and 12% in 1957; these findings are taken as evidence that the 
material did not contain many cases of primary renal disease and that the 
worse prognosis in men is sometimes due to renal complications. Death 
caused by cerebral diseases varied from about 20 to 45% 



Medical News Letter, Vol. 33, No. 8 



In the present investigation, a higher frequency of cerebral deaths 
is foxond, nannely 55%. This may be due partly to the fact that all patients 
who died with cerebral coniplications have been recorded as cerebral deaths, 
although there were symptoms of heart failure or renal complications at the 
same time. This has been found to be correct because the cerebral com- 
plications have been the direct cause of death in these cases. 

Another reason for the high number of cerebral deaths is probably the 
age ramge, because this series consisted of younger individuals under the 
age of 46 at registration who about 16 years later will still not have reached 
the age group in which heart failure symptoms are usual. 

Cardiac conditions, partly heart failure and partly coronary diseases, 
were the dominating cause of death in the earlier investigations. Cardiac 
cause of death is found in only 24% of the nnaterial. The nnajority of such 
deaths were cases of heart failure while coronary artery disease rarely 
was found to be the cause of death. Only 6 women (8%) and 6 men (9%) died 
of myocardial infarction. There is a striking resemblance between the per- 
centage distribution of causes of death recorded in the two follow-up inves- 
tigations in 1950 - 1951 and in 1957. 

At the last follow-up in 1957, few patients were found who were unable 
to work. Patients working part time were frequently found among housewives, 
but approximately one -half of the patients living tried to fill a full-time job. 

The prognosis was found to be much better in patients with a labile 
diastolic hypertension — i. e, , patients whose diastolic blood pressure went 
below 95 mm. Hg during bed rest and treatnnient with sedatives — than in 
patients with a more stabilized diastolic hypertension. Only 7 (13%) of 54 
women and 12 (28%) of 43 men with labile diastolic hypertension died during 
the observation time. On the other hajid, 64 (52%) of 123 women and 48 (75%) 
of 64 men with more stabilized diastolic hypertension died. (Mathisen, H. S. , 
et al. , The Prognosis in Essential Hypertension: Am. Heart J., 57: 371-381, 
March 1959) 

Treatment of Acute Renal Failure 

Within the last decade, much progress has been made in the under- 
standing of renal physiology and disease due to the introduction of electron 
microscopy and percutaneous renal biopsy. 

Acute renal failure is a clinical syndrome which is characterized by 
oliguria -anuria and progressive azotemia with electrolyte imbalance. Dis- 
eases such as acute glomerulonephritis, pyelonephritis, or obstructive 
uropathies are excluded because the injury to the kidney in acute renal fail- 
ure is confined chiefly to the tubular cells and the basement membrane. It 
is true that the aforementioned disease may produce acute renal insufficiency. 



Medical News Letter, Vol. 33, No. 8 



but the term acute renal failure is reserved for those cases which result 
from acute tubular damage produced by either nephrotoxic agents or renal 
ischemia. Acute renal failure is synonymous with the terms acute tubular 
necrosis, acute toxic nephrosis and — probably the most familiar and popular 
one — lower nephron nephrosis. 

This article summarizes experience with acute renal failure at Mil- 
waukee County Hospital during the last 10 years and outlines what is believed 
to be correct principles in managing the anuric patient. Generalities of treat- 
n^ent regimen can only be stated and these must be adapted because each 
anuric patient is a distinct clinical problem. 

The course of acute renal failure is divided into three stages: (1) the 
stage of tubular injury which is of short duration, probably less than an hour, 
(2) the stage of oliguria and anuria which varies greatly in length but averages 
from 8 to 10 days, and (3) the stage of tubular recovery. 

The authors believe that the syndrome may be minimized or even pos- 
sibly prevented from developing if vigorous treatment is promptly instituted 
when the diagnosis is suspected. When hypotension occurs, whether mild or 
severe, treatment should be intensive. The body responds to a fall in blood 
pressure by a generalized vasoconstriction in which the kidney vessels 
participate. The reduction in renal blood flow may cause ischemic change in 
the renal tubular cells, thus producing the syndrome or possibly potentiate 
the changes already produced by a nephrotoxic agent. Therefore, the circu- 
lating blood volume should be maintained by blood, plasma, or plasma ex- 
panders. Pressor substances, such as norepinephrine (arterenol), are of 
value in this stage. Even though they act by causing vasoconstriction, 
thereby initially producing a further diminution in renal blood flow, this is 
short lived because as the blood pressure rises, as shown by Moyer, renal 
dynamics improve. In addition, myocardial contractility is aided which by 
increasing cardiac output improves the renal blood flow. 

When a toxic substance is ingested, it should be eliminated from the 
body or rendered inactive by the use of the appropriate measure as quickly 
as possible. Information from Poison Control Centers now established in 
most major medical centers is of invaluable aid in accomplishing this end. 

Having survived the initial stage of the disease, the patient enters the 
oliguric -anuric phase which is the most critical. Tubular function has 
virtually been destroyed and the patient has no means of excreting the pro- 
ducts of protein metabolism. Their accumulation will ultimately threaten 
his life. More than this, the patient becomes a problem in fluid balance. 
Here it is that the most frequent therapeutic error is made because the 
patient's small fluid requirements are not appreciated and he is overhydrated. 
The anuric patient has no effective means of handling an excessive water load. 

Usually, 600 cc. of water may be safely supplied daily. This figure 
is obtained by subtracting from the daily insensible loss the water of oxida- 
tion which results from catabolic process. To this may be added varying 



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Medical News Letter, Vol. 33, No. 8 



amounts of water up to 400 cc. daily depending upon the degree of variation 
of the patient from the basal state. An equal volume of water must be added 
to replace urine output, and when there is overt loss which usually occurs 
chiefly from the gastrointestinal tract. 

Of aid in checking the state of hydration is the weight of the patient 
which can be accurately determined by the use of a bed scale. An anuric 
patient will lose weight because it is impossible to supply an adequate 
caloric intake. If no daily weight loss occurs, then the weight is being main- 
tained by the accumulation of excessive water. Water intake should be con- 
trolled to produce a weight loss of about 1/2 pound daily. 

The body's small supply of endogenous carbohydrate is rapidly ex- 
hausted. Carbohydrate must be supplied if protein catabolism is to be 
diminished and if oxidation of fat is to proceed without ketosis. A minimum 
of 100 gm. of carbohydrate daily will accomplish this. Because fluid intake 
is limited, hypotonic solutions are necessary to supply this amount. By using 
a 10% sugar solution {glucose or fructose) to which is added 95% ethyl alcohol 
(up to 100 cc. daily), the authors have been able to supply the necessary car- 
bohydrate calories through a peripheral vein. 

Oral intake is routinely discontinued throughout the oliguric stage. All 
fluids and calories are supplied parenterally because only in this way can an 
accurate measure be obtained. Protein catabolism is thought to be further 
diminished by the administration of testosterone propionate in dosage of 
25-50 mg. intramuscularly daily. 

The use of an indwelling urethral catheter is to be avoided because 
of the certainty of renal infection. The patient should void if at all possible. 
If the patient does not void every 24 hours, catheterization is done using 
very careful technique. 

As the suiuria continues and the azotemia increases, the electrolyte 
change of first importance is the rise in the serum potassium because it 
causes a disruption of the conductive system in the heart. The best treat- 
ment of potassium intoxication is its prevention. At no time during the 
oliguric -anuric phase should potassium -containing substances be given. 
Infections, accumulations of blood, and areas of necrotic tissue should be 
treated vigorously because these liberate potassium with cellular destruction. 
Insulin should be given with the carbohydrate for in its presence potassium 
is transferred intracellularly when glucose is deposited in the liver as gly- 
cogen. Twenty to thirty tmits of regtilar insulin administered simultaneously 
with the carbohydrate has been fovind to be adequate. This offers only a tem- 
porary measure, however, because as the glycogen is metabolized potassium 
is returned to the extracellular fluid. Once potassium intoxication has devel- 
oped, the best treatment is dialysis. 

As part of an integrated plan for the treatment of renal failure, the 
artificial kidney is a valuable instrument. It is not a substitute for good 
medical management, but is an adjunct in therapy. It provides meansto gain 



Medical News Letter, Vol. 33, No. 8 



additional time to allow the damaged kidneys to reconstruct themselves if 
possible and to resume physiologic function. 

Important factors in making the decision as to when to dialyze are: 
the evaluation of the patient's general appearance, the cardiorespiratory 
status, and the irritability of the neuromuscular system. The only two 
contraindications to dialysis are: active bleeding from any source, or pro- 
longed hypotension just prior to dialysis. 

Treatment during the stage of tubular recovery, the diuretic phase, 
consists in supplying electrolytes as dictated. by the serum levels and uri- 
nary excretion. Reabsorption by the tubular cells is faulty at this time and 
sodium and potassium depletion may occur. Fluids are given to maintain 
a urinary volume of Z500 to 3000 cc. daily. As azotemia decreases and 
nausea lessens, oral fluids are started. Small amounts of 20% lactose are 
used initially and then other fluids added. Protein foods are generally not 
added until the N. P. N. is below 100 mg. %, and then protein restriction is 
continued until the N. P.N. returns to normal. During this stage, the 
patient is rehabilitated as rapidly as possible with special attention being 
given to the vigorous treatment of any renal infection. 

The prognosis of acute renal failures is poor and is dependent to a 
great degree upon the nature and severity of the precipitating injury or ill- 
ness as well as the extent of the renal lesion. 

Shock was the cause of failure in 21 patients in this study, whether 
surgical, traumatic, or hemorrhagic. Incompatible blood transfusion was 
the second most important causative agent. Whatever the source, renal 
failure is more apt to occur in patients from 30 to 70 yea s of age. 

The mortality may be reduced if the patient is closely managed by a 
regimen which (1) rigidly restricts fluid smd electrolyte intake, (2) controls 
protein catabolism, (3) minimizes serum potassium rise, and (4) supports 
the cardiovascular system. (Schulz, E.G., Murphy, F. D. , Treatment of 
Acute Renal Failure: A.M. A. Arch. Int. Med., 103: 125-130, March 1959) 

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Pulnaonary Cystic Disease 

Cyst formation in the liuigs is gaining prominence as a topic of dis- 
cussion in the current literature on respiratory diseases. Interest in this 
abnormality evolved from observations in the phenomenon of spontajieous 
pneumothorax. Prior to 1932, the latter was universally considered as due 
to tuberculosis. 

Published reports on cystic disease discuss more commonly obser- 
vations on cysts of bronchial origin. An increasing literature on the subject 
indicates, however, that emphysematous blebs and bullae of alveolar origin 
occur more frequently. In reports on bullous emphysema, the occurrence of 



10 Medical News Letter, Vol. 33, No. 8 



spontaneous pneumothorax is a commonly described symptom complex, and 
the procedure of underwater seal catheter decompression of the collapsed 
lung is stated to be a successful therapeutic reieasure in obtaining lung ex- 
pansion. The utilization of exploratory thoracotomy for the purpose of 
carrying out excision of the cystic areas with the view of preventing the 
recurrence of spontaneous pneumothorax is not adequately stressed. Sim- 
ilarly, occurrence of infection within the cyst and henrioptysis, likely caused 
by a sudden increase in pressure within it, are not described frequently nor 
are these complications generally known. Clinical investigators of this sub- 
ject have posed a number of inquiries, such as: their congenital or acqiiired 
origin; whether antecedent respiratory infection may be contributory to their 
development; whether generalized emphysema accompanies localized cystic 
degeneration confined to a lobe or segment of a lobe; and whether a correla- 
tion exists between the severity of symptonns and the number and size of the 
cysts. This article is concerned with the developmental variety of cyst. It 
is characterized by progressive destruction of the interalveolar septa within, 
a lung segment. This leads to bulla or cyst developnnent and ensuing com- 
pression of contiguous lung parenchyma. 

The present study concerns a group of 21 cases of cystic disease con- 
firmed by exploratory thoracotomy which was performed in service hospitals, 
private institutions, and facilities of the Veterans Administration. Observa- 
tions were made with reference to symptomatology, roentgenological abnor- 
malities, history of respiratory infection, incidence of cyst infection, occur- 
rence of hemoptysis, and spontaneous pneumothorax, surgical findings, 
operative procedures, and the histopathological pattern of the resected 
specimens. In evaluating the components of the total picture of cystic disease, 
a striking feature of this study is the high incidence of roentgenological abnor- 
malities that obscured the true nature of the underlying pathology confirmed 
at the time of exploratory thoracotomy. 

Cystic disease has been described variously as "air-cell, " "cystic 
emphysema, " "air cyst, " "giant bulla, " "emphysematous bleb, " "bullous 
emphysema, " "pneumatocele, " "broncho alveolar cyst, " "alveolar cyst, " 
et cetera. It is classified into two anatomical types, bronchial cyst and 
alveolar cyst. The former is considered congenital in origin; the latter, 
acquired. Another classification refers to the mode of localization, such as 
cyst formation within a lobe designated as localized emphysema; and a second 
type, the generalized type in which bullae and blebs are part of a diffuse 
bilateral hypertrophic emphysematous process. 

Recognition of cystic disease on the roentgenograph may be relatively 
easy or extremely difficult. Very small emphysematous bullae or blebs may 
not be recognized. In several reported series in which exploratory thora- 
cotomy was performed to forestall future episodes of spontaneous pneumotho- 
rax, no abnormalities were seen in 91% of preoperative films. The general 
characteristics of cystic disease are ill-defined zones of increa8ed_2:adiance 



Medical News Letter, Vol. 33, No, 8 11 



in some portion or portions of the lung; diminution and sometimes complete 
absence of the bronchovascular markings, the so-called "phantom lung" 
pattern; or a thin wall structure that encompasses an area of increased 
radiance, the so-called air cyst. Moreover, in cystic areas in which con- 
siderable pressure buildup has occurred, a guide to the basic pathology will 
be fo\ind in the compressed portion of the lung lying in apposition to the 
cystic area. Under these circumstances, the compressed portion of the lung 
may be erroneously interpreted as a zone of localized fibrosis. Actually, it 
is an anatomic variation resulting from compression by a neighboring cyst. 
Another phenomenon that is a helpful guide in the localization of lung cysts 
is the recognition of linear bands of density within a zone of increased lung 
radiance. They are called "trabecules" and are the shadows produced by 
fibrous bands that frequently traverse air cysts. They usually arrange 
themselves in a verticeil manner. Regarding the difficulty in recognizing 
the small bullae or blebs that have precipitated episodes of spontaneous 
pneumothorax by their rupture, Shefts et al. report that in their observation 
of such cases they are able to detect the blebs or bullae more readily during 
the early phases of lung expansion. 

Exploratory thoracotomy is proving to be a realistic and fruitful 
approach to the problem of spontaneous pneumothorax, as well as the arrest 
of continuous dyspnea that is associated with cyst formation which is accom- 
panied by compression of normal lung parenchyma. (Joress, M. H. , Pul- 
monary Cystic Disease - Observations in Cases Treated by Exploratory 
Thoracotomy: Dis. Chest, XXXV : 256-264, March 1959) 

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Segmental Resection for Pulmonary Tuberculosis 

Segmental resection made possible through the advent of antimicro- 
bial therapy is an established and accepted procedure in the surgical treat- 
ment of pulmonary tuberculosis. The rate of sputum conversion has been 
found to be high and the morbidity and mortality rates are low. One of the 
greatest values of segmental resection is its preservation of pulmonary 
function. 

Patients with a very limited pulmonary function have been accepted 
for segmental resection, e.g. , resection of two seginents and one sub- 
segment on the only remaining left lung following a previous pneumonectomy. 
Of 335 patients, 12 are dead and 170 have been restudied. Ninety-two pa- 
tients were excluded as the observation time was less than one year. Fifty- 
eight patients refused reinvestigation mainly because they did not like to 
have another bronchospirometry. Of these, many are well and working 
full time, but it has not been possible to obtain a personal restudy. Four 
patients from abroad are well and working, but have not had postoperative 



12 Medical News Letter, Vol. 33, No. 8 



limg-f\mction tests. About one-half of the patients (47%) had bilateral tuber- 
culosis. Seven patients had an open cavity in the contralateral lung. Sixty- 
one patients had had a cavity in the contralateral lung closed at the tinne of 
surgery; in 40 cases by a pneumothorax, in 17 by a thoracoplasty, and in 4 
cases by conservative measures. In 17% an extrapleural resection with a 
decortication of the remaining lung was necessary. 

Age in itself is not a contraindication for segmental resection in 
cavitary tuberculosis. The oldest patient, a 64-year old man, tolerated 
well a segnnental resection of the apical segment of the right upper lobe 
and a small thoracoplasty in one stage. Five years after operation he is 
in good condition and has negative guinea pig tests of the sputum and gas- 
tric washings. cj i. 

The postoperative course must be carefully supervised in older 
patients. Perfusion of blood through nonventilated areas of lung will de- 
crease the arterial oxygen saturation, causing symptoms of coronary ins^if- 
ficiency. When there is an insufficient ventilation in the postoperative 
course which cannot be immediately improved by more conservative roeae- 
ures, a tracheostomy with prolonged artificial ventilation should be insti- 
tuted to guarantee the patient a normal oxygen and carbon dioxide tension. 

Eight patients were operated on under the age of 20, the youngest 
being 9 years old. In 6 of these yovmg patients, no space -diminishing 
procedure was needed. In one, an extrapleural pneumothorax space was 
developed at the end of the resection and filled with air to diminish the 
intrapleural space after the operation. In one patient, the diaphragnn was 
mobilized around its periphery and resutured at a higher level. This latter 
operation is not recommended for general use as it results in impaired lung 
function. However, in young and growing patients under the age of 20, it 
may occasionally be the best space -diminishing procedure. In the above 
case, there was 25% of oxygen uptake on the left side after the procedure. 
The ventilation, however, was only 11%. 

The indications for segmental resection were: (1) tuberculous cavi- 
tation in 314 cases (94%), (2) bronchiectasis with positive sputum in 5 ca^es, 
(3) bronchial stenosis in 2 cases, (4) tuberculous empyema with bronchial 
fistula in 2 cases, and (5) tuberculoma in 12 cases. 

Twelve patients died. The operative mortality was 1.5%. The cause 
of death in 3 patients was ventilatory insufficiency. One 59 -year old woman 
with bilateral cavitary tuberculosis died 2 days after operation in spite of 
artificial ventilation by respirator through a tracheostomy. One 41 -year 
old man had had a tuberculous cavity in the right lung treated by pneumo- 
thorax for 6 years. The third patient who died from ventilatory insuffi- 
ciency was a 38 -year old man who had had a seven-rib thoracoplasty on the 
right side 6 years earlier. A resection of the apicoposterior segment of 
the left upper lobe plus a wedge of left lower lobe was performed for cav- 
itary tuberculosis. One patient died frona hemorrhage despite 13 luiits of 
blood by transfusion. 



Medical News Letter, Vol. 33, No. 8 13 



One 30 -year old patient who, 5 years earlier, had had etn extrapleural 
pneumothorax on the left side for cavitary tuberculosis, underwent resec- 
tion of the posterior segment of the right upper lobe. After operation, she 
vomited and died of an aspiration pneumonia. Seven other patients in this 
series have died since operation. The causes of death included cirrhosis, 
carcinoma, hepatitis, suicide, cerebral hemorrhage; one patient died fol- 
lowing rupture of a tuberculous cavity on the right side 14 months after a 
segmental resection on the left. A 44-year old man died 2 years after oper- 
ation from an unknown cause. Nonfatal complications occurred in 15% of 
cases of segmental resection. 

Of the 170 patients followed from one to 6 years, it has been gratify- 
ing to find 97% with a negative direct smear and 94% with a negative culture 
and guinea pig test of sputum and gastric washings. Ninety-two percent 
were working full time. The incidence of impaired arn) movements, pain, 
cough, and dyspnea was recorded. The best cosmetic result and best arm 
movements were obtained when no thoracoplasty was added. The diaphragm 
mobilization gave the best cosmetic but the worst functional result of the 
different space -diminishing procedures. The osteoplastic thoracoplasty 
gave a better cosmetic result and better arm movements when compared 
with a thoracoplasty with rib resection. There was a higher incidence of 
postoperative pain in the group in which rib resection thoracoplasty was 
performed. The late functional result was encouraging and it has been 
proved that segmental resections can be performed with a minimal loss of 
function. The contralateral side withstood resection very well, (Bjo'rk, V. O. , 
Segmental Resection for Pulmonary Tuberculosis - An Analysis of 335 Cases; 
J. Thoracic Surg. , 37:135-147, February 1959) 

sic sfe 3ic s4c 3k ^ 

Study of Patients with Acute 
Large Bowel Obstruction 

In many patients with carcinoma of the colon, acute intestinal obstruc- 
tion develops at some time in the evolution of the symptom complex. The 
obstruction may be mild and spontaneously reversible. When it persists, 
a serious physiologic problem is added to that of cancer. Two hundred 
and twenty-seven patients with colon cancer complicated by obstruction of 
the large intestine are presented. In these cases, the disease did not 
permit the surgeon to follow the usual course of elective definitive resec- 
tion. In every instance, there was the challenge of the urgent situation 
produced by acute obstruction; the patient had to be salvaged from the emer- 
gency situation before treatment of the primary disease. The authors were 
particularly interested in studying the following aspects of this problem: 
(1) pathologic ana torn y of the obs true ting lesion; (2) pathologic physiology of 



14 Medical News Letter, Vol. 33, No. 8 



the acute colon obstruction; (3) presence of associated small bowel disten- 
tion; (4) physiologic basis and the scope of treatment; (5) indications for 
emergency surgical decompression of the large bowel; and (6) the use of 
cecostomy and transverse colostomy. 

One thousand and five consecutive patients with carcinoma of the 
colon were studied. In this group, 227 patients demonstrated colon obstruc- 
tion. This is said to be present when the normal passage of intestinal con- 
tents is hampered; clinically, it is manifest by obstipation with varying de- 
grees of abdominal pain and distention. Confirmatory evidence is offered 
by scout films of the abdomen and operative findings. Well over three- 
fourths of the obstructive lesions were in the left portion of the colon. 
Twenty percent of the obstructions, however, were found to have stemmed 
from lesions of the right segment of the colon. 

The commonest gross lesion encoxintered was the annular constricting 
lesion. This was complicated in about one-fifth of the instances by necrosis 
and ulceration, and by variants of the inflammatory process: edema and 
abscess. Obturation obstruction by barium administered by mouth for diag- 
nostic gastrointestinal series was noted in 10 patients. 

What causes a chronic, slow growing constricting lesion to obstruct 
acutely the lumen of the bowel? Including the few obturation obstructions 
with those tumors demonstrating gross inflammatory changes, a credible 
answer may be found for about one-quarter of these patients. The nmech- 
anism is a rapidly reversible one and probably accounts for the often re- 
corded clinical observation of ease of relief of obstruction by self-admin- 
istration of enemas and passage of feces and flatus following surgical 
decompression operations. 

About three-quarters of these patients complained of colicky abdom- 
inal pain. Somewhat less than one -half had obstipation, lasting 3 to 5 days, 
and vomited nrjore than once daily. Eight patients presented themselves with 
historical and physical features leading to a clinical diagnosis (including 
^radiography) of apparently pure small bowel obstruction on admission. At 
the time of admission, approximately one-fourth of these patients had dis- 
tention and hyperactive peristalsis. Evaluation of the scout film of the 
abdomen at the time of admission demonstrated slight to marked small bowel 
distention in 40% of these patients. 

A distended snnall bowel — whatever the cause — must be reckoned with. 
Vigorous preoperative replacement with fluids and electrolytes is indicated 
when small bowel distention is recognized. Geriatric patients with serious 
metabolic, respiratory, and cardiovascular disease are affected; the compli- 
cating medical condition may be adversely affected and may decide the issue 
in the face of fluid and electrolyte losses caused by small bowel obstruction. 
Tube decompression is the mainstay of the preoperative preparation and 
should be included in all such cases. 

The data demonstrate the changing character of the problem of obstruc- 
ting colon carcinonria. While, in 1945, Kankin was able to state that most of 



Medical News Letter, Vol. 33, No. 8 15 



these cases of obstruction could be managed successfully with conservative 
nonsurgical measures, about three-fourths of the patients in this study needed' 
surgical deconnpression. Ramkin, as did Wangensteen, alluded to the appear ~ 
ance of small bowel distention as a late sign in the syndrome of large bowel 
obstruction. It was recognized that small intestinal obstruction could result 
from direct extension of the malignant and inflammatory process of the 
colon. No emphasis was placed on the more subtle types of small bowel 
distention due to either malfunction or dysfunction of the ileocecal colic 
segment. 

As Wangensteen demonstrated in the small bowel, the majority of 
the niaterial in the large bowel is of extrinsic origin; changes in the large 
bowel develop as a result of the dysfunction in the terminal ileum. It is 
this segment of bowel in the patient with the diseased colon that offers 
resistance to the gradient of emptying from the small bowel into the large 
bowel. At the same time, it is this segment that continues to empty into 
the obstructed colon. The result is not only a closed loop obstruction, 
but what is termed a '^tension closed loop obstruction" arising from the 
greater sensitivity and the greater muscular activity and contractility of 
the terminal ileum and the ileocecal papilla in comparison with the right 
segment of the colon or cecum. Except in cases of barium enema, the 
pressures in the right segment of the colon never approach the larger 
pressures that exist in the terminal small intestine. 

These pathophysiologic considerations should be reflected in the ther- 
apeutic approach to the problem. First of all, probably in every case, a 
certain degree of small bowel obstruction exists. Consequently, Levin 
tube and long tube suction are of tremendous immediate importance in the 
emergency treatment and preparation of the patient. This decompression 
helps prevent the continued emptying of the terminal ileum into an already 
distended colon. Regardless of the improvement achieved with the suction 
for the small bowel, it is important to keep in mind the concept of tension 
closed loop in the colon. If there is not relief of the obstruction in the large 
bowel in a matter of 12 to 24 hours, surgical intervention becomes impera- 
tive. 

It is difficult to see how there can be a controversy between the conser- 
vative regimen of therapy and surgical decompression. The authors' exper- 
ience indicates that one cannot do without the other. The conservative regime 
should be instituted as an emergency in these seriously ill patients. Time 
must be taken for supportive therapy, tube suction, and antibiotic and £uiti- 
spasmodic medication. Of equal importance, is the time necessary to make 
a complete diagnosis not only of the intestinal situation, but also of the entire 
noedical status of the patient, particularly the cardiovascular, metabolic, 
nutritional, and hematologic status. Usually, in 12 to 24 hours the patient is 
vastly improved. The medical and surgical diagnosis is clarified. In 25% of 
cases the conservative regimen may obviate the necessity for surgical decom- 
pression preliminary to resection. In approximately three -fourths of the 



16 Medical News Letter, Vol. 33, No. 8 



patients, surgical decompression is indicated because no flatus has been 
passed and there is no indication that the obstruction in the large bowel has 
relented to any degree. In patients who are well prepared, surgical decom- 
pression will be more successful with less nnorbidity and mortality. In a 
certain number of patients, it maybe possible to do a definitive resection, 
particularly with lesions of the right segment of the colon and the cecum. 

Most interesting to consider is the place of surgical decompressive 
measures, specifically cecostomy and transverse colostomy. In the average 
situation, cecostomy is safer and is as effective as a decompressive nianeu- 
ver. The authors' clinical and experimental studies support this contention. 
Further, there is evidence to support the statement that cecostomy for de- 
compression followed by resection is an effective and safe course of therapy. 
Mortality is considerably lower when this plan is followed in both the poor 
risk and the average patient. 

Standardization of the therapy for obstructing carcinoma of the colon 
is another recent development. Obstruction resection has given way to 
staged surgical decompressive operation followed by resection with end-to- 
end anastomosis of the colon. Side-tracking in-continuity procedures were 
rare in this series. There were an appreciable nunmber of "palliative" col- 
ostomies. That these are not palliative is apparent considering the average 
mortality of 4Z% when this operation is elected. The authors believe that the 
surgeon should make every effort to achieve resection for palliation in this 
type of patient. (Ulin, A. W. , et al. A Study of 227 Patients with Acute Large 
Bowel Obstruction Due to Carcinoma of the Colon: Surg, Gynec. & Obst. , 
108 : 267-271, March 1959) 

>fi: if/: ij; :^ ilf ii: 

Prophylactic Castration in Carcinoma of the Breast 

The beneficial effects of oophorectomy as a palliative procedure in 
advanced mammary carcinoma have been known for more than 60 years. 
With increasing knowledge of the relationship of certain malignancies to 
hormonal functions — particularly the estrogen-dependent carcinonnas of 
the breast— castration by surgical means or by irradiation of the ovaries 
has become more widely practiced in the management of metastatic cancer 
of the breast. 

In contrast to the acceptance of castration as a palliative measure in 
ihe treatment of advanced cancers, the suppression of ovarian function 
either by surgery or by irradiation as a prophylactic method before metas- 
.lases occur, has been a controversial problenr). 

Smith and Smith studied the effect of prophylactic castration on 101 
patients operated upon for cancer of the breast. Of these, 60 underwent 
oophorectomy and 41 received radiation therapy to the ovaries. As compared 



^ 



Medical News Letter, Vol. 33, No. 8 17 



with a group of noncastrated patients, the survival rates were higher among 
the castrates, "the most striking and statistically significant differences 
being in those with axillary metastases ... In the analyses with reference 
to age, the difference of the highest significance was between the castrates 
aged 50 through 59 and the uncastrated controls of the same age. •' Although 
in this group, the results following irradiation of the ovaries were not as 
favorable as those after oophorectomy (40% survival rate in the irradiated 
groups as compared with 74% in the surgical groups), they were apparently 
sufficiently encouraging to lead to the authors' conclusion that "the alterna- 
tive when surgical castration is refused or contraindicated is adequate ovar- 
ian irradiation. " 

The authors' observations comprise a total of 275 women who were 
below the age of 50 amd had been referred to the Tumor Clinic of Michael 
Reese Hospital during the 10 -year period, January 1942 through December 
1951. These patients were referred for follow-up examinations after radi- 
cal mastectomy or, more frequently, for postoperative local x-ray therapy. 
Sixty- six patients were lost to follow-up studies before the lapse of 5 years; 
in 9 patients, it was not possible to determine whether or not they had f\inc- 
tioning ovaries. The remaining 200 patients have been observed for a per- 
iod of 5 to 15 years. All had undergone radical mastectomy for cancer of 
the breast; at the time of operation, there had been no clinical manifestation 
of metastatic spread beyond the axillary lymph nodes, although there is no 
proof that these patients had no distant metastases. - 

A Table shows the survival rates of the observed 200 patients separat- 
ed into the castrated and the uncastrated groups and into two age groups: 
those under 40 and over 40 years of age. Of 78 castrated women, 46 (59%) 
were alive at the time of the completion of this survey; of 122 not castrated, 
44 (36%) were living. The most favorable resiilts were obtained in the age 
groups over 40 with a survival rate of 68. 8% among the castrates; the poor- 
est results were fovind in the same age group among the noncastrates with a 
survival rate of only 35. 3%. In the younger age group, the survival rate 
after castration was 52. 5% as connpared with that of 38% without castration. 

The patients discussed in this review represent Etn unselected group 
except that only women below the age of 50 were considered; the majority 
of these patients were still menstruating regularly at the time of treatment, 
and in all of them some degree of ovarian activity may be assumed. It is of 
interest to note that Smith and Smith achieved the most striking improve- 
ments in survival rates in the age group between 50 and 59» causing theai to 
advocate the use of castration in women up to the age of 70 with axillary 
metastases. The authors' favorable results in the age group between 40 
and 50 (68. 8% survival) are also suggestive and seem to indicate that the 
suppression of ovarian function may be of considerable importance in the 
later premenopausal, menopausal, andearly postmenopausal periods. 
Whether axillary lymph-node involvement, emphasized by Smith and Smith 



18 Medical News Letter, Vol. 33, No. 8 



as being important, is of great significance appears doubtful in the light of 
recent investigations. Wyatt et al. covtld demonstrate that in over 50% of 
cases of primary malignant tumors in the medial and subareolar areas of 
the breast, secondary implants were found in the lymph nodes of the mam- 
mary chEiin; yet less tham 15% of this group had axillary metastases. 

Results as shown in a Table indicate that prophylactic castration sig- 
nificantly delayed the occurrence of metastases and subsequent death in 
that group which did not survive. 

No practical methods to determine the degree of estrogen dependence 
of carcinomas of the breast in premenopausal women has yet been found 
which could facilitate the indication for castration. The results of this clin- 
ical survey, although comprising only 200 patients, appear to be sufficiently 
significant — even on a statistical basis— to indicate castration either by 
surgical removal or by adequate irradiation of the ovaries in all women with 
ovarian activity as soon as feasible after radical mastectomy. Castration 
also is suggested to all women beyond the menopause who still show signs 
of estrogen production as indicated by tests of the vaginal mucosa. It is 
known that an appreciable number of women, even after removal of the 
ovaries, exhibit evidence of extragonad estrogen production. 

It is believed that these observations form sufficient justification for 
advocation of prophylactic castration in all women with carcinoma of the 
breast who either are still menstruating regularly or otherwise exhibit 
signs of ovarian activity. (Rosenberg, M. F. , Uhlmami, E. M. , Prophy- 
lactic Castration in Carcinoma of the Breast: A. M. A. Arch, Surg. , 78; 
28-31, March 1959) 

jBc j fe jfe j fi c jjt stc 

From the Note Book 

1. The U. S. Naval Hospital, Oakland, Calif. Blood Bank has been granted 
a Certificate of Accreditation by the American Association of Blood Banks, 
the first such accreditation to be given to a U. S. Military Hospital Blood 
Bank by the Association. In the letter accompanying the certificate, 

Dr. Ralph M. Hartwell, President of the Association, wrote, "Those to 
whom these certificates are issued should be proud of their achievement, 
of complying with the most stringent administrative and technical standards 
for blood bank operation that have been compiled to the present time. " 

(TIO, BuMed) 

2. The Bureau of Medicine and Surgery has received a letter from the 
President and Vice President of Creighton University, Omaha, Neb. , honor- 
ing the achievements of CAPT G. W. Hyatt MC USN who is presently serving 
at the Naval Medical School, National Naval Medical Center, Bethesda, Md. , 



Medical News Letter, Vol. 33, No. 8 19 



as Director, Tissue Bank Department. CAPT Hyatt received his medical 
education at Creighton, graduating in 1943. (TIO, BuMed) 

3. Three Medical officers attached to the Bureau of Medicine and Surgery 
are scheduled to present papers at the Annual Meeting of the American 
College of Physicians in Chicago, 111., 20 - 24 April 1959. CAPT H. L. Alvis 
MC USN, Director of BuMed's Submarine Medicine Division, will present a 
paper entitled, "Problems Common to Ships of Inner eind Outer Space. " 
CAPT C.F. Gall MC USN, Special Assistant for Medical and Allied Sciences, 
Office of Naval Research, will discuss "The Biological Stresses of Confine- 
ment under High Oxygen Partial Pressure, " and CAPT N. L, Barr MC USN, 
Director of BuMed's Astronautical Division, will present a paper, "Surveillance 
and Measurement of Physiological Response to Space Flight. " (TIO, BuMed) 

4. The second class in Nuclear Nursing which began on the l6th of March 1959, 
at the Naval Medical School, NNMC, Bethesda, Md. , is a prime example of 
the interservice and people to people relationship of a group intensely con- 
cerned with the humanitarian application of accelerated nuclear developments. 
The current class is composed of seven Nurse Corps officers of the Military 
Services, Department of Defense, one nurse from the Veterans Administration, 
an Assistant Professor of Nursing from the University of Colorado, and three 
Foreign Nurse Corps officers. (NNMC) 

5. An excerpt from a personal letter to the Surgeon General from a Retired 
Medical officer states "... Some 31 years after graduating from medical 
school, I have finally entered private practice and find it most delightful 
and rewarding especially in a financial way. One thing is certain - when 
medical officers retire, they need have no fear for there are plenty of oppor- 
tunities for men who have the training, background, and experience one picks 
up in passing during their Navy careers. You can reassure all of them to 
have no worries about their future ..." 

6. Rheumatic fever, arteriosclerosis, and hypertension constituted 73,5% 
of the causes of heart disease among 3,245 studied cases from all provinces 
of Turkey. In females, the leading cause was hypertension; in male, arterio- 
sclerosis. Rheumatic heart disease was seen in the younger age groups and 
arteriosclerotic and hypertensive heart diseases were seen in the older age 
groups. (Am. Heart J. , March 1959; I. Lutfi, M. D. , L. Veral, M. D. , 

R. Yuceulug) 

7. The treatment of edema is one of the challenges presented to the phys- 
ician. Excess retention of sodium and water is associated with a number of 
pathological conditions. Diuretic agents are valuable additions in therapy 
through their ability to block the reabsorption of sodiurh and water in the 



20 Medical News Letter, Vol. 33, No. 8 



renal tubules. However, these drugs do not cure the disease states associated 
with edema and the basic measures necessary to correct the underlying path- 
ology should be used when such are available. (Dis. Chest, March 1959; 
M. Fuchs, M. D., J, Moyer, M. D. ) 

8. In a review of cases of acute myocardial infarction, it is concluded that; 
patients not receiving anticoagulation therapy have 3 times the morbidity 
and mortality of a comparable group receiving therapy; anticoagulants are 
effective and should be used in both good-risk and poor-risk patients; anti- 
coagulants should be started as soon as possible after onset of the acute myo- 
cardial infarction. (A. M. A. Arch, Int. Med., March 1959; CAPT F. G. Conrad 
USAF (MC), N. O. Rothermich, M.D.) 

9. An analysis of 1,810 frozen sections is presented to show their accuracy 
in specific organs. The accuracy obtained for the entire series was 97, 6%. 
For specific organs, the accuracy varied between 94. 3% for lymph nodes 
and 100% for other organs. For breasts and thyroids, the tissue most fre- 
quently examined, the accuracy was 98. 1% and 96. 5% respectively. (Surgery, 
March 1959; T. Winship, M, D. , R.V. Rosvall, M.D.) 

10. Fifty thymic tumors including 21 adenomas, 13 carcinomas, 2 malignant 
lymphomas, and 9 thymic hyperplasias are reported. Criteria of thymic 
cancer, cytologic peculiarities of the thymic tumors that accompanied myas- 
thenia gravis, aregenerative anemia, or Cushing's syndrome and the differen- 
tiationby special staining of granulomatous thymic carcinoma from Hodgkin's 
disease are discussed. (J. Thoracic Surg. , March 1959; G. D. Andritsakis, 

M. D. , S. C, Sommers, M. D. ) 

11. A review of 15,784 deliveries with 472 perinatal deaths in the four years 
of study is presented in detail. The major causes of death were reviewed 
and tabulated. Prematurity and atelectasis were the most common causes. 
(Am. J. Obst. & Gynec, March 1959; J. T. Downs III, M. D., M. Kurilecz, 
M.D.) 

12. The authors report the results of clinical and laboratory follow-up studies 
in a series of 42 patients in whom direct venous shunts have been carried out 
for portal hypertension. The follow-up period varied from 1 to 8 years. 
(A. M. A. Arch. Surg., March 1959; C. E, Sedgwick, M.D., H. A. Hume, M.D.) 

:jc :^ 9^ :^ $ ^ 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 June 1958. 



Medical News Letter, Vol. 33, No. 8 21 

A Letter from the Surgeon General 



25 March 1959 



'Dear Doctor Gell: 



As Surgeon General, I am particularly proud that the American Astronau- 
tical Society recently selected you as the recipient of the Melbourne W. 
Boynton Award for Space Medicine for 1958. This is a great honor to 
you and to the Navy Medical Corps. 

Please accept my sincere congratulations as the recipient of this dis- 
tinguished award, based on the scientific experimental work you conducted 
in explosive decompression and multicrew long duration confinement. The 
information obtained in this experimental work has led to the establishment 
of significant physiological criteria, which will be of inestimable value in 
the field of Space Medicine. 

A copy of this letter is being forwarded to the Bureau of Naval Personnel 
for inclusion in your official record. 

Sincerely yours, 
/s/ 

B.W. Hogan 

Rear Admiral MC USN 

The Surgeon General" 

Captain Charles F. Gell MC USN 
Office of Naval Research 
Department of the Navy 
Washington 25, D. C. 

sic ■& sk sic sk sic 

Board Certifications - Inactive Reserve Officers 

American Board of Anesthesiology 

LT Stephen P. Murphy MC USNR 
LT Max M. Zung MC USNR 

American Board of Internal Medicine 

LCDR William T. Bailey Jr. MC USNR 



22 Medical News Letter, Vol. 33, No. 8 



Americetn Board of Ophthaltnology 

LTJG Carl G. Freese Jr. MC USNR 

American Board of Otolaryngology 

LT Fairfax V. Breneman MC USNR 

American Board of Pathology 

LT Edwin B. Herring MC USNR 

American Board of Pediatrics 

LT Harvey Lee Carter Jr. MC USNR 
LT Norman L. Miller MC USNR 

American Board of Physical Medicine and Rehabilitation 
CAPT Leo Rosenberg MC USNR 

American Board of Psychiatry and Neurology in Psychiatry 
LCDR Ro swell H. Fine MC USNR 

American Board of Surgery 

LT Loring E. Sylvester MC USNR 

American Board of Urology 

LCDR Wilford A. Councill Jr. MC USNR 
LTJG Raymond M. Yow MC USNR 

9k idc dSi sk sic sfe 

Opportunities Open in Nuclear Submarine 
Medicine Program 

Medical officers who are completing internship and those eligible for 
rotation by the first of July should be interested in knowing that a few vac- 
ancies exist in the Submarine Medicine Class convening early in July 1959. 

The rapid expansion of the nuclear powered submarine program has 
dictated the development of a short course which now is included as part of 
the basic course. There still are opportunities for duty with diesel powered 
submarine squadrons and diving organizations. Early submission of appli- 
cations by interested individuals is urged. They should be airmailed to Chief, 
Bureau of Medicine and Surgery (Attn: Professional Division), in accordance 
with BuMed Instruction 1520. 3B. Any who desire more detailed information 
are encouraged to write to Submarine Medicine Division, BuMed. 

(SubmarMedDiv, BuMed) 

Sfe ??! jfe S JC JJC jfe 



Medical News Letter, Vol. 33, No. 8 23 



Caisson Disease or Diving Accident 
NavMed-Sie 

Report of Caisson Disease or Diving Accident (NavMed 816) was 
revised in February 1956, but reports still come in on the 1945 version of 
this report forn^. It is a reasonable supposition that very few of the older 
forms are still available. It would facilitate the organization of data from 
such reports if all activities would utilize the 1956 version in the future. 
The proper form should be available from the usual source of steindard forms. 

(SubmarMedDiv, BuMed) 

:{;:{: :{c 3je 3ic sjc 

Recent Research Reports 
Naval Medical Research Institute, NNMC, Bethesda, Md. 

1. Study of Induced Radiation in Dental Materials. NM 008 015. 04. 01, 14 May 
1958. 

2. Illustration of a Kinetic Analysis: The Myosin B-ATP-EDTA System. 
NM 01 01 00.02.04, 11 July 1958. 

3. Thermal Radiation Burns in Rabbits. lY. The Distribution of Phosphorus 
and Radiophosphorus (P^^) Fractions in Flash-Type Burns of the Rabbit Ear. 
NM 007 081.03.08, 6 November 1958. 

4. Report on Social Psychiatry - A Therapeutic Commtmity at the U. S. Naval 
Hospital, Oakland, Calif., NM 73 03 00.01.01, 7 November 1958. 

5. Studies on the Functional Organization of the Vertebrate Retina. NM 04 01 
00.02.01, 5 December 1958. 

6. Further Response of Acetylcholinesterase and of Conduction in Bullfrog 
Sciatic Nerve to the Stereochemistry of Amine Inhibitors. II. NM 02 02 00 
.01.10, 12 December 1958. 

7. Changes in Infectiousness of Malarial Gametocytes, II. Analysis of the 
Possible Causative Factors. NM 52 01 00.04.01, 12 December 1958. 

8. Acetylcholinesterase Inhibitory Activities of Muscarine and Muscarone 
Derivatives. NM02 02 00.01.il, 18 December 1958. 

9. A Tachometer for High-Speed Dental Rotary Cutting Instruments. Memo- 
randum Report 58-8 related to NM 008 015.08, 31 December 1958. 

10. Inhibition of Distinctive Cues and Psychophysical Judgment. Memorandum 
Report No. 58-9 related to NM 15 01 00.01, 31 December 1958. 

11. Effect of Stimulus Predifferentiation on Subsequent Generalization of a 
Galvanic Skin Response. NM 15 01 00.01.02, 31 December 1958. 

12. Some Pharmacologic Properties of Holothurin, an Active Neurotoxin from 
the Sea Cucumber. NM 02 02 00.01. 12, 9 January 1959. 



24 Medical News Letter, Vol. 33, No. 8 



Naval Medical Research Unit No. 3, Cairo, Egypt 

1. The Evaluation of Therapy of Schistosomiasis in a Controlled Population. 
Report No. 1. The Use of Intravenous Tartar Emetic in 31 Patients with 
Urinary Schistosomiasis. NM 72 01 03. 3.01, June 1958. 

Naval Air Development Center, Johnsville, Pa. 

1. The Development of Dynamic Flight Simulation. Report No. 1, NM 11 02 
12.6, 4 December 1958. 

2. Adaptation to Positive Acceleration. Report No. 4, NM 1 1 01 12.3, 23 
December 1958. 

Naval School of Aviation Medicine, NAS, Pensacola, Fla. 

1. A Study of Early Greyout Threshold as an Indicator of Human Tolerance 
to Positive Radial Acceleratory Force. Subtask No. 1, Report No. 1, NM 11 
02 11, 10 July 1958. 

2. Relationship among Fundamental Frequency, Vocal Soiind Pressure, and 
Rate of Speaking. Subtask No. 1, Report No. 77, NM 18 02 99, 5 August 1958. 

3. Reading of Messages of Different Types and Numbers of Syllables under 
Conditions of Delayed Side-Tone, Subtask No. 1, Report No. 78, NM 18 02 99, 
10 August 1958. 

4. Reception of Messages of Different Lengths. Subtask No. 1, Report No. 79, 
NM 18 02 99, 15 August 1958. 

5. Effect of Specified Levels of White Noise upon Flicker Fusion Frequency. 
Subtask No. 1, Report No. 80, NM 18 02 99, 18 August 1958. 

6. Relationship between the Frequency Spectrum of Speech and Scores Yielded 
by Multiple -Choice Intelligibility Tests. Subtask No. 1, Report No. 81, NM 18 
02 99, 21 August 1958. 

7. Stabilization of Multiple Regression Weights through Factor Analysis - An 
Empirical Evaluation, Subtask No, 1, Report No. 30, NM 14 02 11, 26 August 
1958. 

8. A Study of Discrepancy between Level of Aspiration and Ability. Subtask 
No. 1, Report No. 16, NM 16 0111, 1 September 1958. 

9. Transfer Effects of Special Training upon Pre-Solo Flight Training. Sub- 
task No. 13, Report No. 1, NM 16 01 11, 18 September 1958. 

Naval Medcial Research Umt No. 2, Taipei, Taiwan 

1. Mouse Adaptation of the Asian Influenza Virus. NM 52 05 02. 4. 3, 1 Nov- 
ember 1958. 

2. Goat Red Blood Cells in the Agglutination Test for Infectious Mononucleo- 
sis. NM 52 11 02.4.2, 25 February 1959. 



Medical News Letter, Vol. 33, No. 8 Z5 

BUMED INSTRUCTION 6220. 2 18 March 1959 

From : Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical Corps Personnel 

Subj: Poliomyelitis (Letter Report, Med-6220-2) 

Ref: (a) BuMedlnst 6310. 4, Subj: Morbidity Report, NavMed-1390 

(Med-6310-2); and Special Epidemiological Reports (Med-6200-2) 

This instruction requires a report on patients with poliomyelitis. 

sk sic sk sfic sfic sjc 

BUMED NOTICE 6320 30 March 1959 

From: Chief, Bureau of Medicine and Surgery 

To: All Naval Activities in Areas Other than the Continental United States, 

Alaska, Hawaii, and Puerto Rico 

Subj: Dependents' Medical Care in Civilian Facilities in Areas Outside the 
Jurisdiction of the Executive Agent 

Ref: (a) SecNavInst 6320. 8 (CH-2) 
(b) BuMedlnst 6320. 22 

This notice clarifies the changes to the dependents' medical care program 
which became effective 1 October 1958, from the standpoint of authorized 
care in civilian medical facilities \ander the provisions of reference (a). 

sjjf ?te ?fe s6f sflc }8c 

BUMED NOTICE 1306 31 March 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Ships eind Stations Having Medical Personnel 

Subj: Hospital Corpsmen; availability, training, distribution and utilization of 

This notice disseminates information relative to the availability of hospital 
corpsmen, and reiterates the policy of the Bureau of Medicine and Surgery 
relative to their training, duty assignment, and utilization. 

sk 3iiC vGc sjc sk sSfi 



26 



Medical News Letter, Vol. 33, No. 8 



OEIMTAL 




SECTIOIM 



Dental Officers Selected for Long 
Courses of Instruction 

The Dental Training Committee, Dental Division, Bureau of Medicine 
and Surgery, selected the following Navy Dental Corps officers for postgrad- 
uate, residency, and specialized training during Fiscal Year I960: 



General Postgraduate Course, U. S. Naval Dental School 



CDR Amos W. Cave DC USN 
CDR Charles W. Folkers DC U3N 
CDR William R. Gabrels DC USN 
CDR Seymour (n) Hoffman DC USN 
CDR Clyde R. Parks DC USN 
CDR Edwin M. Sherwood DC USN 
CDR Carl L. Wilhelm DC USN 
LCDR Andrew J. Bartosh DC USN 
LCDR Theodore E. Carlson DC USN 
LCDR Robert (n) Cohen DC USN 
LCDR Esthel D. K. Ikenberry DC USN 
LCDR "C" P. Johnson, Jr. , DC USN 
LCDR Samuel J. Sachs DC USN 
LCDR John R. Schweitzer DC USN 



LCDR Alan E. Smith DC USN 

LT Robert J. Adams DC USN 

LT Gerald M. Bowers DC USN 

LT Arthur L. Davy DC USN 

LT Thomas A. Garman DC USN 

LT Walter J, Gorman DC USN 

LT Jefferson F. Hardin DC USN 

LT Donald C. Hauck DC USN 

LT William R. Hiatt DC USN 

LT Harris J. Keene DC USN 

LT John P. Kelley DC USN 

LT Wendell E. Montgomery DC USN 

LT Steven W. Perand DC USN 

LT Louis R. Pistacco DC USN 



There were 53 applicants for the 28 billets in the General Postgraduate 
Course. Because it is considered desirable in the Bureau of Medicine and 
Surgery that all Regular Navy Dental officers below the grade of Captain re- 
ceive this training, those whose requests were disapproved were encouraged 
to reapply. 

Residency Training in Oral Surgery 

CAPT Albert L. Oesterle DC USN - U, S. N. H, , Great Lakes, 111. 

CDR Ingram W. Ogden DC USN - U. S. N. D. S. , NNMC, Bethesda, Md. 

LCDR Harry J. Dennis DC USN - U. S.N. H. , Portsmouth, Va. 

LCDR Homer S. Samuels DC USN - U, S.N. H. , St. Albans. Long Island, N. Y. 



Medical News Letter, Vol. 33, No. 8 27 



Residency Training in Prosthodontica, U. S. N. D. S. » NNMC, Bethesda, Md . 
CDR Marvin Carmen DC USN 
CDR Tomas C. Pablos DC USN 

Residency Training in Periodontics, U. S. N. D. S. , NNMC, Bethesda, Md . 
LCDR Corey H. Holmes DC USN 

Specialized Courses, U. S. N. D. S. , NNMC, Bethesda, Md . 
CDR Peter C. Conglis DC USN - Periodontics 
L,CDR Stephen O. Bartlett DC USN - Maxillofacial Prosthesis 

Long Course in Civilian Institution 

CDR Walter J. Hillis DC USN - Periodontics 

™ " T* ^ T T 

New Vice President for Dental Research Unit 

CAPT James A. English DC USN, Head, Dental Branch, Office of Naval 
Research, and Head, Dental Branch, Research Division, Bureau of Medicine 
and Surgery, was elected Vice President of the International Association for 
Dental Research during the recent meeting of the Association in San Fran- 
cisco, Calif, 

****** 
Reenlistments of Dental Technicians 

During the period, July through November 1958, 40.5% of all eligible 
career petty officer separatees of the Dental Rating Group XI reenlisted in 
the Navy. The following is a breakdown of reenlistments by rate; 

Chief Dental Technician - 100% 
Dental Technician, First Class - 100% 
Dental Technician, Second Class - 38% 
Dental Technician, Third Class - 18% 
Total Over -All Average - 40. 5% 

j^ sfe ite ^ jftc sfc 

Revised Dental Standards for Women 

Attention is invited to the recently instituted revised dental standards 
for original enlistment of women in the Navy and Marine Corps. Applicants 



28 Medical News Letter, Vol. 33, No. 8 



must have at least twenty teeth. Satisfactory artificial replacements may 
be counted in lieu of natural teeth. An applicant must have no more than 
five carious teeth as determined by the Type Four screening examination 
as described in Chapter 6, Manual of the Medical Department. 

The revised dental standards are effective on receipt of Advance 
Change 7-10, Manual of the Medical Department. 

>ji :$e sJe :^ :{c sic 




RESERVE SEm0I\ 



Training in the Naval Reserve 
Types of Training 

1. Active duty for training is full time duty with the Regular com- 
ponent of the Navy for training purposes and is provided as follows: 

a. Active duty for training 

b. Special active duty for training 

c. Group active duty for training 

2. Inactive duty training is any of the training, instruction, duty, and 
appropriate duties, or equivalent training, instruction, duty, appropriate 
duties, or hazardous duty performed with or without compensation by mem- 
bers of the Naval Reserve as prescribed by the Secretary of the Navy and 

in addition thereto includes the performance of special additional duties, 
as may be authorized by competent authority, by such members on a vol- 
untary basis in connection with the prescribed training or maintenance 
activities of the unit to which Reservists are assigned. Work or study per- 
formed by such Reservist in connection with correspondence courses shall 
be deemed inactive duty training for which compensation is not authorized. 
The following types of inactive duty training are provided: 

a. Regular drills 

b. Eqxiivalent instruction or duty 

c. Appropriate duty 

d. Correspondence courses 

e. Naval Reserve communication network 



1 




Medical News Letter, Vol. 33, No. 8 29 



Active Duty for Training 

(1) Active duty for training is required for personnel attached to or 
associated in pay status with pay units. Active duty for training is also 
authorized for a limited number of other personnel including those who are 
performing appropriate duty, associated in non-pay status with pay units, 
attached to non-pay units, and those in the Active Status Pool. 

(2) Commandants are authorized to prescribe the type of active duty 
for training for Reservists under their jurisdiction. The type of duty 
assigned should be that most appropriate to the Reservist's grade and desig- 
nator or rating and classification, his Naval Reserve status, and his pros- 
pective mobilization billet. 

(3) The Chief of Naval Personnel will issue schedules and quotas for 
active duty for training for Reservists. 

(4) Active duty for training with or without pay, exclusive of travel 
time, shall not exceed 14 days axinually, unless specifically authorized by the 
Chief of Naval Personnel. 

(5) Commandants are authorized to release Reservists attached to or 
associated in pay status with pay units of the Naval Reserve from their obli- 
gations to perform active duty for training upon evidence of good and suf- 
ficient reasons. Reservists failing to perform the required training shall 
submit a request for waiver containing the following information: 

(a) Fiscal year for which submitted 

(b) Date of enlistment or appointment 

(c) Date assigned to the pay imit 

(d) Dates of active duty or active duty for training performed 
during preceding 4 years, or since enlistment (if serving in first enlistment). 

(e) Previous years released from obligation to perform active duty 
for training, stating the reason. 

(f) Number of drills attended during preceding fiscal year 

(g) Reasons for failure to perform active duty for training. Com- 
manding officers shall verify the information contained therein and forward 
the request with an appropriate recommendation to the cognizant comman- 
dant for action. All requests of this type concerning members of any organ- 
ization shall be forwarded at the same time by the commanding officer with 
recommendations. 

(6) Active duty for training will be performed in ships or shore activi- 
ties designated for this purpose by the commandant in accordance with cur- 
rent instructions issued by the Chief of Naval Personnel. 

(7) Civilian employees of the Navy may not be assigned active duty for 
training in the same billet nor in the same office in which employed as a 
civilian. Further, they shall not perform active duty for training in conjunc- 
tion with, or concurrently with, the performance of any civilian travel orders. 



30 Medical News Letter, Vol. 33, No. 8 



Special Active Duty for Training 

(1) Special active duty for training is defined as active duty for training 
in excess of 14 days but nor more than 90 days' duration. Special active duty 
for training may be approved by the Chief of Naval Personnel from time to 
time for special purposes and, when approved, may be performed in addition 
to regularly scheduled periods of active duty for training. 

Group Active Duty for Training 

{I) Reservists may be authorized to perform group active duty for 
training in ships or at shore activities. Pay is not authorized for this type 
of training. 

(2) Group active duty for training is computed separately from the 
annual 14 days' active duty for training and may be performed in addition 
thereto without prior approval of the Chief of Naval Personnel. 

(3) The combining of a series of group active duty for training periods 
totaling 14 days or more cannot be used as a substitute for the annual 14 days' 
active duty for training reqviired of personnel of pay units, 

5JC sfe ife s}c ifc ifc 



AVIATION MEDICINE DIVISION 




Status of Navy Full Pressure Suit Program 

1. The full pressure suit and helmet consist of (less controller) about 
l600 parts. The Research and development on the full pressure suit began 
at the Air Crew Equipment Laboratory, U. S. Naval Air Material Center, 
Philadelphia, Pa., in 1946. 

2. Current Production Model Suit - Mark IV, Light Weight Suit, being 
manufactured by the B. F. Goodrich Company. 

3. Aircraft Configured for the Full Pressure Suit 

a. Compatibility of the suit with the F4D-1 aircraft has been approved 
by the Naval Air Test Center, Patuxent River, Md. , provided the ejection seat 
face curtain handle is extended. This is not an extensive job and the Naval Air 
Test Center has satisfactorily modified their test aircraft to an acceptable 



Medical News Letter, Vol. 33, No. 8 31 



configuration. (VX-3 is conducting further studies of the suit-urgent com- 
patibility problems. ) 

b. The Naval Air Test Center approved the compatibility of the 
suit with the F8U-1, -IP, and -2 aircraft, provided; 

(1) The D-500 Connposite Disconnect is removed from the air- 
craft. (F8U-ASC-264) 

(2) The Back Pan Control System is modified by removing the 
emergency oxygen bottle and providing a hose to connect to the existing emer- 
gency oxygen bottle in the seat pan. (See Aviation Clothing and Survival 
Equipment Bulletin Number 20-58. ) 

In advance of the issuance of these two modification instructions, the 
Bureau of Aeronautics has purchased 108 kits covering both required mod- 
ifications. Fifty-four (54) of these kits are currently available at the Naval 
Air Station, Norfolk, and the other fifty-four (54) at the Naval Air Station, 
North Island. Accordingly, the necessary F8U modifications can be accom- 
plished at any time that they are required. 

c. Although the F4H- 1 aircraft is not of immediate concern in 
Fleet operations, contractor test pilots and NPE pilots (U. S. Navy test 
pilots specifically assigned to evaluate the aircraft) have successfully flown 
the aircraft while wearing the suit with no problem areas reported to date. 

d. The A3J-1 aircraft is configured to accept the svdt; NPE and 
contractor test pilot flights indicate there are no major problems with the 
suit. 

4. Pressure Siiit Training Program Status 

a. Full Pressure Suit Training Units : Two of these units are in 
existence; one at the Naval Air Station, Norfolk, and one at the Naval Air 
Station, North Island. In addition to fitting, training and indoctrinating 
pilots, they also have the responsibility of assisting \jtnits in the field in 
solving various operational problems. To date, these units have indoc- 
trinated several hundred pilots who have since flown the suit in actual air- 
craft. 

b. Parachute Riggers' Training: The Parachute Riggers' School, 
Naval Air Technical Training Unit, Lakehurst, N. J. , has had a Full Pres- 
sure Suit Course since May 1956. This is a 4-week course that can be taken 
either separately or as a part of the 17-week Parachute Riggers' Course, 

To date, 127 students have been graduated and, of this number, 47 have 
taken the 4-week course only. 

c. Training Film : A squadron training film has been prepared 
and is presently being edited for release in April 1959. This film details 
suit sizing, donning procedures, and general familiarization with the 
eqtiipment. 

d. Training Devices ; The Naval Training Device Center's Device 
9 -A- 11, a series of projectable color slides, covering details of the equip- 
ment is currently available in the supply systenn. 




32 Medical News Letter, Vol. 33, No. 8 

a. Publications: Adequate publications are in the supply system 
or are scheduled for early issue. These include: 

(1) NavAer 00~80T-7I, Space Training Unit . This is an indoc- 
trination publication of full pressure suits and is currently available in the 
supply system. (It is being brought up to date to cover the Mark TV suit. ) 

(2) Maintenance Handbooks and Illustrated Parts Catalogs are 
in the final stages of preparation and will be available in the supply system 
on or before 1 June 1959. 

(3) NavAer 00-8022-127, Charts . This is a series of illus- 
trative charts on pilot equipment including pressure suits; sets are currently 
available in the supply system. 

(4) Aviation Clothing and Survival Equipment Bulletin covering 
the operation, test, and general use of the Mark IV suit and control system 
has been prepared and is now available. Two smt controller Aviation Cloth- 
ing and Survival Equipment Bulletins, Numbers 2-59 and 3-59, are also 
available. The Aviation Clothing and Survival Equipment Bulletin Number 
1-59 on the Mark IV suit is under revision. A new printing is expected in 
May 1959. 

5. Test Equipment: This area is considered to be adequately covered 
and consists of the following: 

a. Portable Test Kits for testing against suit leakage and giving 
pilots ground pressurization checks are currently available. These kits 
are also of value in indoctrinating pilots in the use of the suit. Seventy-five 
(75) kits are currently in the supply system and the Aviation Supply Office 
is procuring additional units at the rate of one for each ten suits. 

b. Oxygen Regulator Test Kits . Conventional O2 regulator test 
stands have been satisfactorily modified to test the pressure suit O2 regxila- 
tor and suit controller. Kits are available for this modification in the 
ComNavAirLant area as follows: 

Three (3), Naval Air Technical Training Unit, Lakehurst, N. J, 

One (1), Full Pressure Suit Training Unit, Norfolk, Va. 

One (1), VX-3, Oceana, Va. 

One (1), O&R, Norfolk, Va. 

One (1), O&R, Jacksonville, Fla. 

One (1), O&R, Cherry Point, N. C. 

One (1), Quonset Point, R.I. 
Instructions for the modification of the test stand are contained in Section X, 
NavAer 17-15BC-505, currently available in the supply system. 

c. Communications Test Kits for checking out the helmet communi- 
cations gear are available as required and are considered to be of great value 
in providing an easy means of communicating with a suited pilot. Five of 
these kits have been purchased for purposes of evaluation. 

6, Required Ventilation and Air Conditioning Support : As a result of 
the pressure sealing properties of the suit, adequate ventilation and cooling 



Medical News Letter, Vol. 33, No. 8 33 



is mandatory, particularly during the warm months of the year. This ven- 
tilation niust be supplied from the time of suit donning until the aircraft 
system can take over and supply the required air and temperature control. 

a. Ready Room Ventilation for NavAlrLant Carriers : 

(1) CVA-42 (ROOSEVELT) is currently equipped to supply 
required ready room ventilation and has twenty (20) pressure suit outlets 
in one of the four ready rooms. The rennaining three will be modified in 
1960. 

(2) CVA-59 and -60 will receive a similar system at next over- 
haul in 1961 since this modification has been given no priority for present 
overhaul. 

(3) CVA-62 will be eqviipped in the same manner as CVA-42 in a 
all ready rooms by April 1959. 

(4) CVA-11 will have one ready room equipped with twenty (20) 
outlets in 1959. 

b. Ready Room Ventilation for Shore Stations : 

(1) The most satisfactory system for immediate installation 
is a nriodification of the hangar compressed air system. This modification 
consists of installing a pressure reducing valve and filter, then manifolding 
the reduced and filtered air pressure to 6-8 ready room outlets. VX-3 has 
this modification installed and reports satisfactory results. 

(2) The Bureau of Aeronautics is working with the Bureau of 
Yards and Docks to develop plans for air conditioning hangar ready rooms 
and supplying lockers and suit drying facilities. This work is scheduled to 
begin in 1959 at Lemoore, Calif. 

c. Ready Room to Aircraft Ventilation : 

(1) A very promising nine -pound portable battery-powered 
ventilation unit is currently under test at the Air Crew Equipment Laboratory. 

(2) A two -wheeled hand-pulled unit is under evaluation at the 
Full Pressure Suit Training Unit, Naval Air Station, North Island, and pre- 
liminary reports indicate very good results. 

(3) Onan Kab Coolers mounted on panel trucks will be evaluated 
by the Naval Air Test Center and VX-3. Action has been taken to supply one 
to the Naval Air Station, Jacksonville, Fla. 

(4) In addition to the above, the Bureau of Aeronautics has three 
Research and Development projects to further improve this area of ventilation. 

d. Standby in Cockpit Ventilation (Engine Off) : 

(T) Units under c. (1) and (2) above, are expected to be satisfac- 
tory for this purpose. 

(2) NR-1 and NR-2 carts are currently available for this require- 
ment, but due to size and low pressure delivery, are not considered entirely 
satisfactory. 

(3) A suit vent from the source of air for engine air starters is 
being investigated and looks promising. 



34 Medical News Letter, Vol. 33, No. 8 



(4) The Bureau of Ships is investigating the feasibility of run- 
ning air lines on carrier decks to be available for each aircraft. 

e. Ventilation During Low Throttle Operation (Landing and Taxi ): 

(1) The F8U-1 system is considered marginal in this condition 
and Chance Vought has been requested to submit an ECP for improvement of 
the supply of temperature controlled air. 

(2) Not enough experience has been obtained with the F4D-1 to 
determine the adequacy of its system for the idle condition. Should it prove 
unsatisfactory or marginal, an ECP will be immediately requested. 

(3) A3J-1 and F4H-1 aircraft are apparently satisfactory. 
7. Full Pressure Suit Availability 

a. As previously stated, the current production model suit is 
designated the Mark IV and, although not the ultimate, is considered to be 
operationally acceptable. 

b. A total of 85 of these suits have been delivered. 

c. In addition to the above, 100 of the earlier Mark III suits are 
being modified to the Mark IV configuration by the contractor. All of these 
modified suits will be delivered by April 1959, giving a total of 185 suits 
as of that date. 

d. The Aviation Supply Office is purchasing 400 additional Mark IV 
suits to be delivered at the rate of thirty (30) per month starting in March 1959. 
This new contract will bring the total of Mark IV suits to 585 by May I960. 

e. Spare parts are available now to support all currently available 
Mark IV suits and the Aviation Supply Office is procuring spares in connection 
with the new 400-suit contract for concurrent delivery with suits. 

:(c :(c :(: 3jc s^c ^ 

Liqiiid Oxygen 

A military specification on oxygen, aviator's breathing, liquid MIL-0- 
21749 (Aer) was issued by BuAer on 17 December 1958, Portions of this 
specification are quoted below for information: 
"3. Requirements 
3. 1 Purity. The oxygen when gasified in a closed container shall contain 
not less than 99. 5% by volume oxygen. Except for moisture and other 
minor constituents, the remainder shall be argon and nitrogen. 
3. 2 Minor constituents . 

3. 2. 1 Moisture ^ The oxygen shall contain not more than 0. 02 milligrams 
of water vapor per liter of gas at 70° F. and 760 millimeters of mercury 
pressure. 

3. 2. 2 Hydrocarbons and other . The oxygen shall contain not more than 
the concentration of the constituents shown in Table I. 



Medical News Letter, Vol. 33, No. 8 



35 



TABX£ I 



Constituent 



COo 



CH 



4 

C2H4 

C3 + Hydrocarbons 

Halogenated Compotind:; 
Other 



Maximum Concentration 
in Farts per Million 

5.0 

1.0 

0,05 

0.2 

1.0 

0.1 

0.1 

0.1 



3. 3 Odor . The oxygen shall exhibit no noxious or nauseating odor, 

4. Quality Assurance Provision 
4. 4 Test Procedure 

4.4. 1 Purity . Place a sufficient quantity of mercury in a 100 milliliter 
calibrated nitrometer, provided with a two-way stopcock and a two-way 
outlet, and properly connected with a balancing tube. Connect one of the 
outlet tubes of the nitrometer with a gas pipet of suitable capacity. Place 
in the pipet a coil of copper wire which extends to the uppermost portion 
of the bulb, and add about 125 milliliters of ammonium chloride -ammonium 
hydroxide test solution (made by mixing equal volumes of water and 27% 
concentrated ammonia; then saturate with ammonium chloride) (see 6. 2), 
Draw the liquid (free from air bubbles) through the capillary opening con- 
nection and stopcock opening in the nitrometer by reducing the pressure in 
the nitrometer tube and opening the stopcock controlling connection with 
the gas pipet. Then close the stopcock. Having completely filled the nitro- 
meter, the other stopcock opening, and the other intake tube with mercury, 
draw into the nitrometer exactly 100 milliliters of oxygen by reducing the 
pressure in the tube. Close the stopcock. Increase the pressure on the 
oxygen in the nitrometer tube, and open the stopcock controlling the con- 
nection with the gas pipet. Close the stopcock, and rock the pipet gently, 
providing frequent contact of the liqmd, gas, ouid copper spiral. At the 
end of 15 minutes, when most of the oxygen will have been absorbed by the 
liquid, facilitate the absorption of the remainder by drawing some of the 
liquid into the nitrometer tube and forcing the residual gas back upon the 



36 Medical News Letter, Vol. 33, No. 8 



surface of the liquid in the gas pipet. Again rock the pipet until no further 

diminution in the volume of the gas occurs. Draw the residual gas, if any, 

into the nitrometer tube, and measure its volume. 

4. 4. 2 Minor Constituents . 

4. 4. Z. 1 Moisture . The moisture contact shall be determined by use of 

an approved dew point indicator such as the McMahon type. 

4.4.2.2 Hydrocarbons and other . Hydrocarbons and other constituents 

listed in Table I may be deternnined using an infra-red spectrophotometer 

capable of detecting them in the amounts listed in the Table or by other 

approved methods. 

4.4.2. 3 Odor. Odor shall be determined as follows: 

(1) Cover the bottom of a clean 400 cubic centimeter (approxi- 
mately 1 pint) beaker or similar type container with a clean dry filter 
paper or suitable absorbent paper. Provide a watch glass cover or some 
means of partially covering the top of the container. This cover is required 
to prevent odors from the surrounding atmosphere being absorbed into the 
liqiiid oxygen sample. 

(2) Collect approximately 200 cubic centimeters (approximately 
1/2 pint) of liquid oxygen in the beaker or container. The container should 
be covered while collecting the sample and for the remainder of the test. 
Note : Do not hold beaker with bare hands while collecting sample. 

(3) Allow sample to evaporate to dryness in an area free of air 
currents or any odors. 

(4) Upon reaching dryness, raise cover and smell vapors in 
beaker. The frost which may collect on the outside of the beaker may, 
upon melting, give off odors also. 

6. Notes. 

6. 1 Liquid oxygen plants whose source of air is odorous or otherwise 

contaminated may require special operating procedures or equipment to 

produce breathing oxygen. 

6. 2 The test for purity requires the use of freshly prepared ammonium 

chloride -an^monium hydroxide solutions. These solutions should be aged 

by making five or six runs before taking test data for purity. 

6. 3 Liquid oxygen may be purchased by the gallon, which produces 115 

cubic feet at 70° F- or by the cubic foot. One thousand cubic feet equals 

8. 68 gallons of liquid oxygen. One gallon of liquid oxygen weighs 9. 55 

pounds. Contract should specify weight or volume being purchased. 

6. 4 Requests for sampling equipment or tests of manufactuerers plants 

shall be forwarded to: 

Chief, Bureau of Aeronautics (AE-42) 
Department of the Navy 
Washington 25, D. C, 

j{c sje sj! ^ s}: sic 



Medical News Letter, Vol. 33, No. 8 37 



Intraocular Pressure 

Twenty-five years ago, the canal of Schlemm was regarded as a safety 
valve in the human eye, so that a rise of intraocular pressure above normal 
limits was counteracted by a flow of aqueous fronn the anterior chamber into 
the episcleral veins. Since that time, the measurement of this outflow has 
been the subject of careful study, culminating in the development of methods 
whereby it can be accurately measured. Tonography and the bulbar pressure 
test can show in a few minutes whether the function of the drainage channels 
is below or above average, thereby enabling ophthalmic surgeons to treat 
their cases of glaucoma with some precision. Such studies have tended to 
divert the attention of workers engaged in research on the eye to the anterior 
chamber, and particularly to its angle. Thus, recent literature abounds in 
articles on gonioscopy, tonography, pathological changes in the angle of the 
anterior chamber, pressure changes in the episcleral veins, and so on. 
Indeed, further knowledge of the regulation of the intraocular pressure and 
glaucoma would almost seem to lie in a better understanding of outflow 
dynamics. 

A reaction is setting in against this mode of thought and two comple- 
mentary lines of research are being followed today. The first is biochemical. 
The discovery of the hypotensive action of acetazolamide in glaucoma has 
led to a renewed interest in the chemistry of the eye and to the resuscitation 
of the theory that a redox mechanism, maintained by enzymatic activity in 
the ciliary epithelium, is responsible for much of the secretion of the aque- 
ous and provides energy for its flow. According to this theory, hydroxyl 
ions are generated continuously by the oxidation of reduced cytochrome 
oxidase in the ciliary epithelium, and the neutralization of these ions by 
carbon dioxide accounts for the excess of bicarbonate which is found in the 
aqueous and which gives it an osmotic pull higher than that of the blood. 
Acetazolamide acts by inhibiting carbonic anhydrase, the enzyme which 
normally controls the formation of bicarbonate. This theory, although ques- 
tioned in points of detail, suggests that the formation of intraocular fluid is 
due to a peripheral mechanism under local physico-chemical control. A fail- 
ure in this control may theoretically produce a type of glaucoma which is due 
to excessive production of aqueous. Recently, a series of such cases was 
published, presenting raised intraocular pressure in association with a 
normal outflow as measured tonographically. 

The second line of research stems from the supposition that there is 
a controlling central nervous center, possibly in the hypothalamus. There 
are many clinical and experimental findings which are difficult to explain 
without this supposition, particularly the concensual changes in intraocular 
pressure when alterations are induced in the fellow eye. This hypothesis has 
led to studies of the effects on the intraocular pressure of stimulation of the 
cervical sympathetic trunk and the third and seventh cranial nerves, and to 



38 Medical News Letter, Vol. 33, No. 8 



studies of the effect of stimulation of the fifth cranial nerve. Work has also 
been reported on the changes in intraocular pressure resulting fron} stimula- 
tion of the central nervous system; in particular, the diencephalon has re- 
ceived close attention because this part of the brain is known to influence 
many bodily fimctions. Responses have been obtained showing independent 
variations of the intraocular pressure on stimulating points in the postero- 
dorsal region of the diencephalon and from a circumscribed area in the 
medical hypothalamus. The authors believe that their findings are compati- 
ble with the view that the diencephalon influences the intraocular pressure, 
but they do not allow the conclusion, as yet, that such influence is in the 
nature of a controlling mechanism. Both lines of thought require considerable 
experimental exploration. In the meantime, it would seem desirable to study 
a series of cases of glaucoma in man wherein the outflow channels are func- 
tionally normal, for it may be possible in such a group to decide whether the 
anomaly in fluid formation and intraocular pressure is primarily neurogenic 
or biochemical, and whether centrally or peripherally determined. 
(Medical Digest, Vol. 4, No. 8, August 1958; and Brit. M. J. , J_: 387, 1958) 

iff ij: :i!fi ij: )^ itf 

Health Hazards 

Preventive medicine is an important facet of aviation medicine. Ground 
crew personnel are particularly exposed to occupational health hazards during 
maintenance procedures. With this in mind, the following excerpts from 
Occupational Health Reports are reported: 

"The incidence of dermatitis in this station has increased signifi- 
cantly during the past year. In looking over the possible causes, it was 
ascertained that many complex new materials are now being handled and 
that our system of issue of protective creams was antiquated. It was the 
custom to issue pound-size jars that were, in many cased, used jointly 
by several employees. Occasionally, there were restrictions in the issue 
which discouraged the use of these creams. It was also found that many 
work areas were relatively distant from washing facilities, discouraging 
frequent washing of the hands and encouraging simple wiping under which 
conditions protective cream had no effect, A pilot study was conducted 
in a large shop where aircraft engines and components are handled, over- 
hauled, and repaired. An inventory was taken of the miscelleneous mat- 
erials handled, number of employees concerned, and the availability of 
washing facilities. It was concluded that for the best skin hygiene, dis- 
pensers for both waterless cleanser and protective creams would be the 
most efficient method. Areas were selected for relocation of these units. 
This program has not yet been placed into effect, but it is anticipated that 



Medical News Letter, Vol. 33, No. 8 39 



these changes will be Instrumental in reducing the incidence of industrial 
dermatitis. " 

"A nearby air station requested a survey of aircraft cleaning opera- 
tions due to 14 cases of skin conditions (varying from mild irritations to 
straight burns) which occurred following the use of an emulsion-type 
grease -cleaning compound to remove oil film and carbon soil from the 
surfaces of aircraft. This material comes in two types: 

Type I- (Turco) Stock No. RF6850-559-2835-G500 
Type II - (Delchem) Stock No. RF6850-559-2836-500 
Type 1, a light duty cleaner is normally used; but Type II, a heavy duty 
cleaner was issued to the activity by the Supply Departnfient as a substi- 
tute. Type I is non-phenolic, whereas Type II contains a maximum of 
3% phenol by weight. Exposed personnel experienced a burning sensation 
followed by a reddening of the skin with subsequent peeling. The use of 
face shields, rubber gloves, and wearing of long-sleeved shirts was 
recommended in conjunction with the use of this material. •' 

iii :/ii i^: Hf iff :^ 

New Carrier 

The fighting capability of the carrier will soon be greatly enlarged, 
for now on the horizon is the first nuclear powered attack carrier — the 
USS ENTERPRISE. As a result of its radical power plant, the ENTERPRISE 
will be able to carry appreciably more planes than the conventional, equiva- 
lent sized carrier. It will also be able to carry far more aviation fuel. In 
addition, owing to its atomic engine, the ship will be able to remain "on the' 
line" almost indefinitely under combat conditions. 

The new ship is being bvdlt at the Newport News Shipyard, Newport 
News, Va, Work on the carrier has reached the stage where shielding for 
the nuclear reactor which will drive the propulsion machinery is now being 
installed. (ONR Research Reviews, January 1959) 

^ ^ ^}c ^ ^ ^ije 

Aviation Physiology Training /Indoctrination 

OpNav Instruction 3740. 3B was issued on 25 February 1959. Atten- 
tion is invited to this revised instruction, particularly as it pertains to the 
minimum indoctrination reqidred for selected passengers, foreign nationals, 
and non-crewmember service personnel prior to travel in high performance 
aircraft. 

JJC *f- 3j? ^ 3J^ ^' 



40 



Medical News Letter, Vol. 33, No. 8 



Miniature Flight Surgeons' Wings 

The Permanent Uniform Board has approved the design for miniature 
Flight Surgeons' Wings and arrangements have been made for their manufac- 
ture. They should be available for purchase after 1 May 1959. 

!{s s{e * * * :je 

i 

Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such infornnation. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any itenn 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particvilar interest to the individual. 

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